- Commonwealth Care Alliance (Boston, MA)
- …timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role ... Utilization Management , the Nurse Utilization Management (UM) Reviewer is...**Essential Duties & Responsibilities:** + Conducts timely clinical decision review for services requiring prior authorization in a variety… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- Ready to help us transform healthcare? Bring your true colors to blue. The RoleThe RN Utilization Management Reviewer is responsible for facilitating ... benefit to provide the best quality care. The TeamThe RN Utilization Management Reviewer...+ Licensure in additional states a plus. + For registered nurses only: a bachelor's degree in (BSN) preferred.… more
- Cognizant (Boston, MA)
- …have to be considered** . Educational background - Registered Nurse ( RN ) . 2-3 years combined clinical and/or utilization management experience with ... Eastern Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact...care revenue cycle or clinic operations . Experience in utilization management to include Clinical Appeals and… more
- CenterWell (Boston, MA)
- … RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to ... put health first** Conviva Care Solutions is seeking a RN who will collaborate with other health care givers...DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous… more
- Beth Israel Lahey Health (Plymouth, MA)
- …a job, you're making a difference in people's lives.** Full Time **Job Description:** ** Utilization Review & Denials management manager - Full Time** **Who ... and Barnstable counties. Our Nutrition Services Team consists of registered and licensed dietitians who provide expert nutritional interventions...and Serve Your Community!** **In your role as a Utilization Review & Denials Management … more
- Beth Israel Lahey Health (Plymouth, MA)
- …years recent, broad clinical experience in the hospital setting + Experience with utilization management within the last 3 years required + An understanding ... using Interqual criteria. + Integrates clinical knowledge with billing knowledge to review , evaluate, and appeal clinical denials related to the care provided to… more
- Brockton Hospital (Brockton, MA)
- …responsibilities. EDUCATION: + RN with Master's Degree + Current License as Registered Nurse in the Commonwealth of Massachusetts EXPOSURE CATEGORY: It is ... management experience Proven experience in coordinating discharge planning and utilization review experience required. Prior management experience… more
- Beth Israel Lahey Health (Plymouth, MA)
- …stay, 3) Decreasing unit cost, 4) reducing readmissions. **Duties/Responsibilities:** **A. Utilization Management ** Performs review of anticipated admissions ... This role is structured around four major functions + Utilization Management + Care Coordination + Discharge...be required._ **Education/Experience Required:** _Required_ + State of MA Registered Nurse ( RN ) + 3-5… more
- Beth Israel Lahey Health (Cambridge, MA)
- …SKILLS, AND ABILITIES REQUIRED** 1. RN with experience in risk management , quality assessment, or utilization management . 2. Strong spreadsheet, ... on the key performance indicators and quality measures, the RN specialist also aims to foster a culture of...reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review … more
- Humana (Boston, MA)
- **Become a part of our caring community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills ... and communication of behavioral health services and/or benefit administration determinations. The Utilization Management Behavioral Health Nurse 2 work… more
- Commonwealth Care Alliance (Boston, MA)
- …require intensive care management and care delivery. Within the CIC Program, the Registered Nurse ( RN ) serves as an integral member of an ... utilization , ensuring optimal treatment for chronic disease management , and closing quality gaps. Additionally, the RN... management , including: + 5+ years' experience as Registered Nurse in a high touch clinical… more
- Beth Israel Lahey Health (Needham, MA)
- …practice model. **Job Description:** **Essential Responsibilities:** 1. Performs utilization management , care coordination, and discharge planning ... third weekend & rotating holiday required) Job Summary: The RN Case Manager (CM) facilitates the coordination of care.... 4. Knowledge of discharge planning practices, understanding of utilization review practices including third party payer… more
- Highmark Health (Boston, MA)
- …triaging members to appropriate resources for additional support. + Implement care management review processes that are consistent with established industry, ... **Required** + 7 years in any combination of clinical, case/ utilization management and/or disease/condition management ...in addressing targeted populations **LICENSES or CERTIFICATIONS** **Required** + RN license in PA or WV or DE or… more
- Commonwealth Care Alliance (Boston, MA)
- …member experience. * Address provider inquiries related to care coordination, utilization management , and program participation, collaborating with internal ... does not have direct reports. Essential Duties & Responsibilities: Provider Relationship Management * Serve as the primary relationship manager and point of contact… more
- Beth Israel Lahey Health (Plymouth, MA)
- …a difference in people's lives.** **Job Description:** Are you a case management / utilization review professional passionate about improving care delivery ... **Care Transitions Department** and seeking an experienced **Manager of Utilization Review & Denials Management **...plays a vital role in ensuring seamless, patient-centered care. ** RN - Utilization Review ** This… more
- Blue Cross Blue Shield of Massachusetts (Hingham, MA)
- …health care settings (Inpatient, outpatient, or differing levels of care). + Utilization Management experience, preferred. + Active licensure in Massachusetts is ... Bring your true colors to blue. The Role The RN Case Manager is responsible for facilitating care for...standards to create, follow and appropriately document comprehensive care management plans. + Review medication list and… more
- Highmark Health (Boston, MA)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... and the proper action to complete the retrospective claim review with the goal of proper and timely payment...experience in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder… more
- Humana (Boston, MA)
- …in state of employment + 3 years clinical RN experience + 2 years of Utilization Review , Case Management , or Quality Management experience + Strong ... of action. The Quality Audit Professional 2 supports the Healthcare Quality Management Team in administering and implementing the Clinical Quality Management … more
- Brockton Hospital (Brockton, MA)
- …of five years clinical experience in an acute care facility required. Prior experience in case management , utilization review or discharge planning required. ... of our patients. Provides medical-surgical pediatric and obstetrical case management services to Brockton Hospital patients. Responsible for assuring continuity… more
- Sharecare (Boston, MA)
- …appropriate resource utilization and desired clinical outcomes. The Disease Management Nurse is also responsible during their interactions with participants ... learn more, visit www.sharecare.com . **Job Summary:** The Disease Management Nurse has the responsibility for supporting...with disabilities to perform the essential functions. + Current Registered Nurse multi-state compact license in the… more